Download Benjamin Vialle Medical student University of Queensland

Benjamin Vialle
Medical student
University of Queensland
Psychiatry: Art or science? Questioning the question to see things as they are.
Introduction
Harland et. al. (2004) once characterised a conceptual divide in psychiatry as two opposing camps.
The first camp, they said, focuses on brain functioning, empirical methodology and universally
applicable evidence. The second camp, drawn to psychiatry’s common ground with the humanities,
focuses on cultural relativity and the limitations of the scientific method when studying the mind. Each
camp, they said, by their stubbornness in relation to the other, “risk conceptual disaster at both
extremes” (Harland et. al. 2004, p.363). Indeed, we in each camp fall into the old trap of seeing things
not as they are, but as we are.
Similarly, when we seek to define psychiatry as either art or science – or even both or neither – we do
not define at all. Instead we undefine. We categorise away important subtlety and nuance, and we miss
the bigger picture. There is surely a sense in which psychiatry is a science, and another in which it is an
art. However, to simply fall upon “both” as the answer is too easy and too simple, and is itself reductive.
Instead, we ought to question the question: What do we mean when we call psychiatry an ‘art’ or a
‘science’? Is this a false dichotomy? Only by shining a light on our categories and our questions can we
hope to see things as they really are.
Is Psychiatry a Science?
Saunders (2000, p.18) is right to point out that “doctors’ medical practice is not itself science, it is based
on science”. Clinical medicine could be called applied science, and this is surely what we mean when
we use the term science in this context. In this sense, psychiatry is science as well. Those who
prescribe clozapine, for example, do not undertake ‘science’ themselves, but apply the scientific
evidence collected by others. Other treatments such as ECT, whose mechanism of effectiveness is
less well understood, can be applied with the prediction of success based on observations of previous
success. It all sounds rather scientific indeed. Furthermore, what role will neuroscience play in the
future of psychiatry? Perhaps the practice of psychiatry is destined to flourish into a scientific era of
even greater proportions.
On the other hand, could psychiatry be better called a failed science, in the absence of a universally
accepted paradigm? The affirmation of psychiatry as a science certainly runs dry quickly in comparison
to other areas of clinical medicine. There is no psychiatric biomarker as specific as Troponin I is for
myocardial ischaemia, and no psychiatric screening as effective as a pap smear is for detecting
cervical dysplasia. A psychiatrist might apply ‘science’ in prescribing clozapine, but what about in
diagnosing psychosis in the first place? Is the scientific method utilised in that process? Perhaps we
begin to see why many senior psychiatrists are found to be skeptical about the role of science in
psychiatry (Chur-Hansen & Parker 2005, p.417).
Part of the problem is the ambiguous use of the term ‘science’. When we ask if psychiatry is ‘science’,
what do we mean? We might quite earnestly refer to ‘the scientific method’; we might mean ‘evidencebased’ or ‘based on previous observations’ as in clozapine and ECT; we might mean ‘biologically
understood’ as in Troponin I. The truth is, when we ask if psychiatry is ‘science’ we use a vaporous
term in a particularly cloudy way, and we should not be surprised to find ourselves lost.
Is Psychiatry an Art?
Clearly medicine is to some extent science. Is it art as well? In famously extolling the significance of the
doctor’s whole relationship with the patient, Peabody (1927, p.877) asserts that medicine “is an art,
based… on the medical sciences, but comprising much that still remains outside the realm of any
science”. Those skills that Dr Peabody exalts in person-centred care – listening, compassion,
communication – are reasonably called the ‘art’ of medicine’. Furthermore, just as clinical medicine is
applied science, so that application could be construed as an art: a skill, acquired by experience,
executed with creativity.
There is a claim to be made that psychiatry is in fact the most artful of specialties. Perhaps its
aforementioned limitations in science are precisely why there may be a special kind of art to psychiatry.
By requiring more behavioural interpretation, more communicative prowess, more psychological
insight, maybe psychiatry is even more of an art than other areas of medicine. Indeed, a 2000 RANZCP
Congress poll found that 94% of Fellows present agreed that “the humanities are as important as the
sciences in the proper practice of psychiatry” (Bokey & Walter 2002, p.398). It seems unlikely that
surgeons, gynaecologists and radiation oncologists would agree in such numbers with that statement if
spoken of their specialty.
However, just as ‘science’ is an imperfect descriptor for psychiatry, so too ‘art’ seems hopelessly
limiting. We could not call psychiatry an art at the expense of its genuine need for scientific rigour,
shared terminology and sound methodology. Further, psychiatrists are of course not artists who can
make or break the rules as they see fit. In this sense we do not use the term ‘art’ as we do to describe
painting or theatre, for psychiatry is not merely creative, expressive, didactic, or critical. It is also
pragmatic, has aims, and serves a purpose – it is healthcare, first and foremost.
Saunders (2000, p.18) rightly asks what we are doing when we call medicine an art: “Does it amount to
anything more than romantic rhetoric—a nod in the direction of humanitarianism?” The problem of
ambiguous terminology is even more telling here than before. When we ask whether psychiatry is ‘art’,
what exactly are we asking? By ‘art’ we might mean bedside manner, compassion or interpersonal
skills; we might refer to some kind of talent or ability to interpret and understand people; we might mean
creativity, imagination or metaphor; we might mean the ethical dimension of practice. In canvassing the
views of psychiatrists on whether their field is an art, one study found first-hand how indeterminate that
word can become: “Art was ‘social science’, ‘clinical skills’, ‘rapport’, ‘dealing with patients’, ‘music’,
‘background knowledge’, ‘philosophy’, ‘conceptualization’, ‘humanities’, ‘literature’, ‘culture’,
‘psychotherapy’ and ‘ambiguity’” (Chur-Hansen & Parker 2005, p.416). Once again, by asking our
questions with muddy imprecision, we probably ask the wrong questions altogether.
Questioning the Question
The plainest answer to the question, ‘Psychiatry: art or science?’ is “both”. Perhaps the safe option is to
call psychiatry an ‘artful science’ or a ‘scientific art’. However, the plainest or safest answer rarely offers
the most insight. Instead, what is needed is to question the question.
“Psychiatry: art or science?” is a question based both on ambiguous terms and on a false dichotomy.
We have already clearly seen the ambiguity of the terms. The reality of the false dichotomy emerges
when we realise that these ambiguous terms have been unfairly opposed. The things we are
nebulously calling ‘art’ – creativity, reflection, talent, and human interaction – are all intrinsic to the
process of science. Likewise, that which we imprecisely label ‘science’ – proven methods, evidencebased techniques, and widely accepted paradigms – are central to much of what we are calling art.
There is an art to science, and a science to art.
‘What is art?’ and ‘What is science?’ are indeed two questions whose answers will determine our
evaluation of psychiatry as one or the other, but a third question looms: What is psychiatry, anyway? In
one way that is what we have been asking, but in another, its answer has been assumed all along. For
psychiatry is surely a wide stream, swimming together in which are biological researchers and narrative
psychotherapists alike. To subsume each under the umbrella of psychiatry may be fair enough.
However, to then take the leap of identifying the whole umbrella, and all that lies beneath, as either ‘art’
or ‘science’ is surely an overreach. Simple dichotomies can sometimes appease our insatiable desire to
categorise, but they rarely make insightful sense of complex diversity.
Conclusion
How then shall we answer our question? Psychiatry: art, science, both or neither? The paradox is that
we must ask the question, but we also must question it. In its self-contradictory divergence, questioning
the question makes our enquiry both harder and easier – easier, because we are forced to refine and
clarify, and harder because in so doing we discover yet more ambiguity and mystery. In each sense,
though, the question is made more worthwhile. For at the centre of clarity and mystery is all science
and all art, indeed all human knowledge and experience, and certainly all of psychiatry.
Bibliography
Bokey, K & Walter, G 2002, ‘Literature and psychiatry: the case for a close liaison’, Australasian
Psychiatry, vol. 10, no. 2, pp.393-399.
Chur-Hansen, A & Parker, D 2005, ‘Is psychiatry an art or a science? The views of psychiatrists and
trainees’, Australasian Psychiatry, vol. 13, no. 4, pp.415-418.
Harland, R, Owen, G & Broome M 2004, ‘Humanity and biology in psychiatry’, British Journal of
Psychiatry, vol. 184, p.363.
Peabody, FW 1927, ‘The care of the patient’, The Journal of the American Medical Association, vol. 88,
no. 12, pp.877-882.
Saunders, J 2000, ‘The practice of clinical medicine as an art and as a science’, Medical Humanities,
vol. 26, pp.18-22.